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This finding is consistent with anecdotal reports from many parts of the country. The most highly publicized such report was about Murray Barr, a “chronically homeless mentally ill man” in Reno, Nevada, who in the 10 years before he died in 2005 “cost the county at least $1 million,” including “at least $100,000 in emergency room fees in 6 months in one Reno hospital.” Murray Barr became well known because he was portrayed in a profile, “Million-Dollar Murray,” in the New Yorker , but in fact every urban area in the United States has several untreated, severely mentally ill, and very expensive Murray Barrs. Providing adequate psychiatric treatment to just this small group of individuals would produce enormous savings. 38
Medicare and Medicaid data also suggest that a small number of seriously mentally ill individuals account for a strongly disproportionate share of the total costs. A study of Medicare patients who were rehospitalized within 30 days following hospital discharge reported that patients with psychoses (schizophrenia and bipolar disorder) had the second-highest rate of rehospitalization costs, behind only individuals with cardiac problems. Similarly, a study of Medicaid costs reported that “nearly 60 percent of Medicaid spending is incurred by just 5 percent of the program’s beneficiaries” and that “mental illness is nearly universal among the highest-cost, most frequently hospitalized beneficiaries.” Another study of Medicaid costs for individuals with one of nine different chronic diseases reported that individuals with psychoses were the most expensive, more than three times more expensive than those with diabetes or hypertension. In still another study of individuals with schizophrenia covered by Medicaid,it was estimated that the failure of these individuals to take antipsychotic medication cost Medicaid $1.5 billion in one year. 39
It is clear, therefore, that prioritizing services for a small subset of seriously mentally ill individuals is not only humane and in the best interests of the individual but also economical and in the best interests of society. Indeed, even the 1961 report of the Joint Commission on Mental Illness and Health recommended that individuals with “major mental illnesses . . . should have first call” on available psychiatric services. Despite what would seem to be common sense, the prioritization of the sickest and most problematic psychiatric patients has been tried only occasionally in the United States and never with much conviction. The most ambitious attempt was in Oregon in the 1990s, when a panel of experts, appointed by the governor, prioritized by diagnoses the psychiatric services to be covered by Medicaid. When the plan reached the state legislature, however, it was promptly disemboweled by “local political wrangling” and by advocacy groups that complained, for example, that post-traumatic stress disorder was just as important as schizophrenia. Despite the support of the governor, who was a physician, political will in the state legislature was lacking. 40
8. Services for mentally ill persons must be prioritized to ensure that those who are sickest, pose the greatest risk to themselves and others, and incur the greatest cost receive services as the first priority.
Another problem associated with the prioritization of patients is access to information. Very commonly, police and sheriffs, who are now the frontline mental health workers, are asked to assess mentally ill people but have no access to the person’s history. As early as 1990, in an article titled “What Do Police Officers Really Want from the Mental Health System?,” police officers “indicated that they most needed access to information about an individual’s past history of violence or suicide attempts.” Many of the sickest and most dangerous mentally ill persons travel from state to state, but critical clinical and legal information usually does not cross state lines. For